What’s Your Diagnosis? a 7-year-old boy after a generalized seizure lasting 2 minutes
November 1, 2019
Posted by Andy Jagoda, MD in: What's Your Diagnosis , trackback
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Case Presentation: a 7-year-old boy after a generalized seizure lasting 2 minutes
A 7-year-old boy is brought in by ambulance after a witnessed generalized seizure lasting 2 minutes at home. He has no history of prior seizures. Upon arrival to the ED, he appears postictal and is moving all of his extremities. His blood glucose is 110 mg/dL. His vital signs are: temperature, 36.9?C (98.5?F); heart rate, 60 beats/min; blood pressure, 110/70 mm Hg; respiratory rate, 14 breaths/min; and oxygen saturation, 98% on room air. The boy vomits while the nurse is trying to obtain IV access.
Per the mother, the boy has been receiving chemotherapy for lymphoma and was complaining of a headache earlier in the day. He has no history of intrathecal chemotherapy. The mother does not think he had any head trauma recently.
You know that the child needs brain imaging, but you are uncertain which imaging would be most useful?
You were concerned about a CNS neoplasm in the 7 year-old boy, given his history of lymphoma with new neurologic changes. You were also concerned about intracerebral bleeding and infection that could result from his recent exposure to chemotherapy. His vomiting, low heart rate, and borderline elevated blood pressure were concerning for signs of increased intracranial pressure. As the nurse obtained IV access, you determined that the boy?s mental status was not improving rapidly enough for a typical postictal course, and you were concerned about his airway, given his vomiting. You decided to intubate the boy, and you attempted to get a better neurological examination while the team was preparing for intubation. You also noted there were no signs of trauma. After successful intubation, a CT scan of the head was performed, and it showed intraparenchymal hemorrhage. While the child was on the CT table, you also obtained a CT angiogram of the head. A CBC panel showed a platelet level of 5000/mcL. You discussed the case with the neurosurgeon and hematologist, who recommended transfusing platelets to a level of > 100,000/mcL. Other neuroprotective strategies and ICP precautions were started, and the child was admitted to the ICU.
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